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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781. I' PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or,install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District, I Job Address �T / /�� ✓ Cit Lot Size�-S�x� � PM Owner's Name 4j,46./�` r✓ IY E.5 Address 7�7J /7, �GI1_C�2 phone ii /�'► /_ Contractor_ 42l /'Y elC Address License No. Phone TYPE OF WELL/PUMP:. I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL d —OTHER WELL- S/SUMPS INTENDED USE TYPE OF WELL„ ..,PROBLEM AREA_CONSTRUCTION AT1014S ❑ Industrial 00 pen Bottom ❑ Manteca Dia Dia. of-Well Casing (� ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications V l f 1 Public f Other elta Depth of-Grout_Seal Type of Grout _ ...-_� I Irrigation �..Appth, l I Eastern Surface Seal Installed by _ Repair Work Hone ❑ e of Pump H.P. State Work Done Well Destructi ❑ WeEI Diameter Sealing}Material itop 50'r, r Depth 'fit Filler Material {Below 50') YPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAMADDITION t I DESTRUCTION I (No septic system permitted if public sewer is available within 200 feet.) "Installation will serve: Residence iCommercial_ Other Number of living units: Number of bedrooms # r Character of soil to a depth of 3 feet: "# -�+- Water table depth , � f SEPTIC TANK ❑ type/Mfg Capacity— No. Compartments PKG. TREATMENT PLT. ❑ e w i Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines -«> _.-.". Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line Il _ SEEPAGE PITS ( I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. '. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." I : The applicant must all for all uired inspections. Complete drawing on reverse side. igned Title: Lrl Al 15op— Date: (all _2c FOR DEPARTMENT USE ONLY Application Accepted by Date ` Area Q Y ' I Pit or Grout Inspection b Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 104 ❑ Tracy 835 5 Applicant - Return all copi s to. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 E //,2-1 .° -To W +`s e Ci FE l INFO AMOUNT DUE AMOUNT REMITTED ,-lt RECEIVED BY DATE PERMIT NO. �yjJ�� + EH 19.2e IREV.t/951 35 �� ^nr l